Sciatica – Causes, Symptoms, Diagnosis, Treatment

Sciatica may be defined as the debilitating, inflammatory conditions of the largest nerve in the human body that are originating in the lower back and from the ventral rami of spinal nerves lumber 4 and sacral 3 nerve root in which the patient experiences acute and chronic intolerable pain, sharp, shooting burning pain, paresthesias, itching, numbness, muscle cramping, irritation or compression pain, loss of motor and sensory function in the distribution of the sciatic nerve or an associated lumbosacral nerve root that contains fibers from both the posterior and anterior divisions of the lumbosacral plexus to traveling posterior back through the lower limb to the backside of the thigh to leg calf muscle to as far down as the heel of the foot to phalanges.

The sciatic nerve provides directly motor function to the hamstrings muscle, lower extremity adductors group of muscle, and indirect motor functions to the calf muscle, anterior lower leg muscles, and some intrinsic foot muscles. The sciatic nerve also, indirectly the sciatic nerve provides sensation to the posterior and lateral lower leg muscle as well as the plantar foot muscle.

Causes of Sciatica

  • The prolapsed intervertebral disc, or PLID
  • Herniation or bulging lumbar intervertebral disc
  • Lumbar spinal stenosis in old age may cause the sciatical.
  • Spondylolisthesis or retrolisthesis and misalignment of one vertebra causes sciatica
  • Lumbar or pelvic muscular spasm
  • Inflammation may impinge a lumbar or sacral nerve root that may lead to sciatic symptoms.
  • A spinal or paraspinal mass including tumor, and malignancy.
  • Epidural hematoma, and epidural abscess
  • Piriformis syndrome,
  • Trauma and fracture in the lower back
  • Post-operative and failed back surgery syndrome complications,
  • Pelvic fracture and gynecologic conditions
  • Surgical scarring in the lower back
  • Neural ischemia and edema

Symptoms of Sciatica

  • Acute and chronic intolerable pain – sharp, shooting burning pain, paresthesias, itching, numbness, muscle cramping, irritation or compression pain, loss of motor and sensory function in the distribution of the sciatic nerve or an associated lumbosacral nerve root that contains fibers from both the posterior and anterior.
  • Mid-buttock pain – It may radiate down the leg, most often unilaterally or bilaterally in the right side or left side sciatica. You can experience paresthesias, itching pain in a dermatomal distribution, either Lumber or L5 or sacral S1 depending on where the sciatic nerve is being irritated.
  • Thigh Pain and weakness – In this case, you can feel the backside thigh pain and weakness of the thigh muscle.
  • Radiating Pain – It is the most common symptom of sciatica. Radiating pain may feel worse in running, walking, or bending in the front side.
  • Muscle cramping – It is the common problem of sciatica syndrome, involuntary muscle cramping is seen in the backside muscle in the buttocks, thigh, lower leg.
  • Paresthesia and weakness – In this case entrapped nerve pain with radiation are more common in the right side or left side sciatica there may be weakness while attempting to bend the knee or while pointing the foot or toes upward or downward.
  • Numbness – Frequently loss of sensation may occur when the nerve impulses can pass through the sciatic nerve. The most common affected numbness muscle is the side of the calf muscle, the heel muscle, sole muscle, and top of the foot muscle.
  • Paresthesia. It is an abnormal sensation felt on the skin in the thigh, buttock, and leg muscles. This sensation may include tingling, sudden itching, tightness, pins-and-needles may be felt.
  • Crawling feeling – along the back of the thigh and leg muscle is another symptom of sciatica in the left leg or right leg sciatica.
  • Pain may be aggravated by coughing, sneezing, segmental distribution, and alignment of your body.
  • Muscle spasm, spasticity, may found in the lower leg. It also decreases muscle tone.
  • Pain may increase when long time walking, traveling
  • Pain may felt intolerable in a long time sitting to standing.
  • The sciatica pain is severe or it may suddenly increase pain any time without causes.
  • There is the loss of bowel and/or bladder control
  • In some cases, the sciatica pain is accompanied by fever, nausea, and weight loss

In sciatica right side or left side may be positive resulting in straight leg raising, or loss of strength, muscle power, or sensibility disorders in reflexes test of Achilles or knee tendon, the sensibility of lateral and medial sides of feet and toes may be felt, the strength of big toe during extension may be decreased, walking on toes and heel left side or -right side leg differences, crossed Lasègue’s sign may be found

Diagnosis of Sciatica

Observation of posture and function
  • In standing shoulders – were shunted to the left side, her back was extended and pelvis anteriorly tilted, and there was visible hyper-tonicity of the lumbar paraspinal muscles.
  • This shunted antalgic posture – is commonly referred to as a lumber list. Observation of a lumber list, unfortunately, is a test lacking in reliability (Clare, Adams, & Maher, 2003). Maitland (2005), however, teaches us that if a person presents with an observable postural deformity, they are going to be more challenging to get better. In Sally’s case, she had a contralateral list (shoulders listed to the opposite side of back/leg pain), which is thought to respond more favorably to treatment than an ipsilateral list.
  • In my experience antalgic postures – are very important to detect because they indicate a protective position; a mechanism which the body is adopting (often subconsciously) in the acute phase of injury to protect the injury, and if the antalgic posture is not carefully examined and carefully corrected, it can make the patient a lot worse.
  • Movement tests – It is a manual test that assesses the spine’s range of motion may include bending the neck or torso forward, backward, or to the side with inward. Additionally, if raising one leg in front of the body worsens leg pain in tingling sensation, it can indicate a lumbar herniated disc (straight leg raise test).
  • Muscle strength – It is a neurological examination to investigate the PLID and sciatica may be conducted to assess muscle strength and determine if a nerve root is compressed by a herniated disc. A muscle strength test may include holding the arms or legs out to the side or front of the body to check for tremors, muscle power, muscle atrophy, or other abnormal movements.
  • Reflex test – It is a neurological test to investigate the nerve root irritation or compression that is associate with sciatica that can dampen reflexes in the arms or legs. A reflex test involves tapping specific areas with a reflex hammer. If there is little or no reaction, it may indicate a compressed nerve root in the spine.
  • Straight leg raising – In this condition the patient supine position. The test is positive if there is ipsilateral pain between 10 to 60 degrees arising. This test is quite sensitive about 90% in cases, but not specific. If this test elicits pain more than 90 degrees in the contralateral leg, it should assume disc herniation or nerve root compression problem.
  • Cross straight-leg test – It is a passive examination to identify the nerve root compression. The straight-leg test is performed by having the patient lay in a relaxed, supine position. The examiner then lifts the leg from the posterior aspect flexing at the hip joint and keeping the knee in full extension, or keeping the leg straight forwardly. Typically pain felt between 30 to 70 degrees of hip flexion and experienced primarily in the back pain is likely due to a lumbar disc herniation. Pain and parenthesis that are felt in the leg are likely due to lateralizing compression of a peripheral nerve. While not absolute, musculoskeletal causes of the pain will usually reproduce pain above 70 degrees of flexion and below 30 degrees of flexion.

https://youtu.be/lZm4j6Ls128

Lab Tests

  • Laboratory tests – Leukocytosis is one of the most important tests for sciatica in the right side leg or left side leg that supports the possibility of infection and bone-related disease in the thigh. Blood cultures, urine examination, stool examination, or other possible primary sites of foot bone infection that obligatory when a septic infectious joint is being considered for examination. The elevated inflammatory condition markers like ESR or CRP include suggesting an infectious or inflammatory disease condition may involve.
  • A serum uric acid level – It is often considered by clinicians and doctors when a kidney or other abnormality is suspected, but it is not a reliable and dangerous condition as it may be spuriously elevated or high in acute inflammatory conditions or acutely during a or not.
  • Ultrasound – It is basically done to investigate the thickness of the fascia, tendon, nerve, ligament injury in the spine with sciatica in right side leg or left side leg pain.[]
  • Musculoskeletal ultrasound – It can further visualize the tendon and bony attachment of in the lumbar spine, muscles, ligaments, and nerves. Ultrasound can also be used to identify the area and extent, nature of the injury and used to evaluate periodically during the recovery phase. pain

Imaging

  • Radiographs – Conventional X-ray and radiography is the most widely used imaging system and allows for the detection of bone fractures, osteoporosis, and abnormal pathologies condition like fracture, osteoporosis, erosions, osteonecrosis, osteoarthritis, or a juxta-articular bone tumor, neoplasm, and sciatica in right side leg or left side leg pain. Characteristic features of in sciatica in the right side leg or left side leg include marginal osteophytes formation, joint space gradually narrowing, subchondral sclerosis formation in the thigh front side, and backside pain.
  • CT Scan – High contrast CT scan is more effective to diagnose sciatica in right side leg or left side leg pain. Abnormal tendons, ligaments, cartilage, muscles and osteophytes, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc.
  • MRI – It is called magnetic radical imaging is also helpful to find the bone conditions, abnormal tendon, ligament, cartilage, muscle and osteophyte, synovial fluid. It also helps to identify the bone tumor, necrosis, abnormal joint condition, etc. It is the final stage test to confirm that all sciatica in the right side leg or left side leg pain or any other abnormality. suspected others condition heel pain, such as tarsal tunnel syndrome, soft tissue injury and bone tumors, osteonecrosis, osteomyelitis, subtalar arthritis, and stress fracture.[,]
  • Nerve Conduction velocity test – It a special test for leg pain on both sides or right and left side leg associate with sciatica. It is the procedure where test the sensation of the peripheral nerve stimuli to send the central nervous system means brain. It helps to identify the nervous system sensory and motor problem from the central to the peripheral cell.

Treatment of Sciatica

Patient Education

  • Use of hot or cold packs for comfort and to decreased inflammation in-home treatment
  • Avoidance of inciting activities or prolonged sitting/standing as low as possible
  • Practicing good, erect posture with spine mechanism
  • More engaging in exercises to increase core strength
  • Gentle stretching of the lumbar spine muscle and hamstrings group of muscle
  • Everyday light exercises such as walking, swimming, or aromatherapy
  • Use of proper lifting techniques from one place to another.

Non-pharmacological treatment

  • Cold packs – In the initial stage, you can use cold packs to get relief from a painful area for up to 20 minutes several times a day.  Regularly use an ice pack or a package of frozen peas wrapped in a clean towel may help to erase the sciatica pain on either the right side or left side sciatica.
  • Hot packs –  Hot packs may be used for long time treatment plan. Your doctor may advise you to apply hot or cold packs alternatively. Use hot packs, a heat lamp, or a heating pad on the lowest setting area. If you continue to have pain, try alternating warm and cold packs at the same time.
  • Physiotherapy – It is one of the most common and highly effective non-pharmacological treatments in the world. It has a variety of treatment module to erase acute and chronic pain. It is especially helpful in muscle spasticity, spasms related to thigh front side and backside pain. Inflammatory and noninflammatory pain is treated by ultrasound, MRI, Shortwave, microwave, wax therapy, IRR, laser therapy, interferential current therapy, iontophoresis, manual traction, isometric exercises, auto traction, Maitland therapy, manual traction exercises with a corset.
  • Exercise to increase muscle power – Different types of exercise may be done under the supervision of a physiotherapist or healthcare provider. It falls into the active range of motion, tapping, isometric movement, active range of movement, or passive range of motion exercise of right leg or left leg sciatica.
  • Stretching – It is one of the most helpful treatments to reduce muscle pain, spasm, spasticity that is gradually increasing due to old age and not perform daily workouts or activities. Stretching in the calf and hamstring and quadriceps groups of muscle may help to erase paresthesia, numbness, and sciatica pain by increasing blood.
  • Bracing – It is one of the most important self-help devices that is used in the back spine maintaining proper joint position, reducing swelling, improve posture and maintain the range of motion exercise.
  • Acupuncture – It is the China-oriented acute and chronic treatment system where are needle is used to stimulate the pain receptor to reduce pain. It is also helpful in some spasticity formation pain, stroke, hemiplegia, and chronic rheumatoid arthritis, and acute and chronic sciatica.
  • Spinal manipulation – It is the conservative treatment for sciatica that is applied manually by the physiotherapist to reduce the muscle spasm, spasticity, vertebrae displacement, nerve root compression removing by applying manipulation.
  • Traction – It is consisting of intermittent Tru-Trac, Spina-Trac, greater than 45 kg traction daily your doctor may advise you to decompress the lumbar spine nerve root.  The auto traction and corset, compared with other types of traction. Your doctor may also advise you to take the traction stimulation instrument, infrared heat, or corset alone. [rx]
  • Stretching –  Stretching exercises for your low back pain, sciatica, lumbago, can help you feel better and might help relieve nerve root compression. Your doctor may advise avoiding jerking, bouncing, or twisting during the stretch and try to hold the stretch for at least 30 seconds for your back and thigh muscles.
  • Maintain proper posture – Choose the most comfortable seat with good lower back support, armrests, and a swivel base during the time of travel. Your doctor may advise you to place a pillow or rolled towel in the small of your back to maintain its normal curvature of the spine.
  • Use good body biomechanics – According to your lifestyle or jobs, working place you can avoid to stand for long periods, rest one foot frequently. When you lift something heavy, let your lower extremities do the work properly. Move straight up and down. Try to keep your back straight and bend only at the knees. Avoid lifting and twisting simultaneously even if you have the habit try to stop it.
  • The calf muscle and hamstring stretching – It is a very easy and self-treatment system to perform in your home keeping the towel near the bedside and perform before going to bed and taking the first step in the morning and continue to Pull back on foot for 30 seconds 3 times with 30 seconds of rest in between.[rx]
  • Diet – Diet may be normal or according to the doctor mentions food you can take for you, such as papaya, banana, potato, nut cereal, seasonal fruits, and drink of water. In your daily routine meal must have magnesium, calcium, iron, zinc, folate, vitamin B complex, Vitamin A, Vitamin C, etc.

Medications

  • NSAIDs – It is considered to be the fast-acting nonsteroidal anti-inflammatory drugs (NSAIDs) as including acetylsalicylate, naproxen, ibuprofen, indomethacin, and etodolac, ketorolac in pain is acute pain. But in case of chronic pain piroxicam (40 mg/day), indomethacin (dosage unclear) or phenylbutazone (600 to 1,200 mg/day), Prescribe drugs, if necessary, according to four steps: (1) paracetamol, (2) non-steroidal anti-inflammatory drugs, (3) tramadol, paracetamol, or non-steroidal anti-inflammatory drug in combination with codeine, and (4)morphine [rx]. It is also an effective anti-inflammatory for in thigh front side and the backside pain when used at high doses, due to the decrease or inhibition of prostaglandin synthesis. It is also called one of the oldest NSAIDs used for multiple joint pain. NSAIDs work by inhibiting cyclo-oxygenase to prevent the synthesis of prostaglandins, prostacyclin, and thromboxanes.
  • Muscle relaxant – It is important for patients with chronic muscle spasms, wasting, and muscle cramping releasing drugs. The drugs are tolperisone HCL, eperisone, baclofen, dantrolene, tizanidine, etc [rx]. The drug increases the blood supply with oxygen and nutrition to the affected nerve and joints.
  • Nerve relaxant –  It is basically used to reduce neuropathic pain, inflammation, nerve root entrapment, myalgia, neuralgia, and fibromyalgia, and thigh pain in the front side or backside. Your doctor may prescribe gabapentin, pregabalin, vitamin B1, B6, B12, etc. Major side effects are abdominal pain, nausea- vomiting.
  • Vitamin B1, B6, and B12 – It is essential for neuropathic pain management, pernicious anemia, with vitamin b complex deficiency pain, paresthesia, numbness, itching with diabetic neuropathy pain, myalgia, etc. A side effect may be nausea- vomiting, abdominal pain, cramping.
  • Calcium & vitamin D3 To improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate approximately 500mg per day in different dosage may be taken.[rx]
  • Corticosteroid injections – It is used to healing the nerve inflammation and clotted blood in the torn fascia, tendon, ligament, nerve injury, or compression that is accumulated and leads to sciatica.  Epidural steroids, such as methylprednisolone (2 to 10 mL of an 80 mg preparation), compared with control (epidural saline, intraspinal ligament saline, and sacral hiatus lignocaine) are used to erase sciatica, and nerve root compression. The injections may provide temporary pain relief anywhere from days to several months. With repeated injections, several times the patient may experience a more permanent improvement in their symptoms.[rx] The steroid injections are typically used in severe conditions when normal treatment can not respond.[rx] Common side effects muscle cramping, increase metabolism, dry mouth, vertigo, blurred vision.
  • Chemonucleolysis and chymopapain – Chemonucleolysis is a technique that is now rarely used. It attempts to decrease the volume of disc herniation by reducing the amount of material contained within the nucleus pulposus by injecting the enzyme chymopapain. In some scientific, A systematic review of a lumbar discectomy with percutaneous treatments identified three RCTs that compared chymopapain with other placebo injections and reported that symptom relief was greater in the group that received chymopapain.

Surgery

Common minimally invasive surgeries are

  • Discectomies – During a discectomy, an expert surgeon removes herniated disc material that is pressing on the sciatic nerve.
  • Microdiscectomies – It is a microdiscectomy or microdecompression involves removing fragments of intervertebral discs and others nerve root related abnormality that have broken away and are pressing on the sciatic nerve or spinal cord. Microdiscectomies may also extract bulging or protruding disc, PLID, material that is causing sciatica.
  • Laminectomies – Sometimes, a portion of the vertebral bone called the lamina can be ousted to remove by surgical procedure to heal sciatica.

References

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